DATE:           TIME (24hr): 

I) Learning and memory

      A) Recent memory
[]   0 = Memory for daily events unquestioned.
[]   1 = Occasional failures to recall recent events, placement of keys, no effect on daily function.
[]   2 = Increase of failures to recall recent events, loses keys, defect interferes with daily activities.
[]   3 = New material lost after distraction.
[]   4 = No capacity to retain new information.
[]   5 = No capacity to obtain information.

      B) Remote memory
[]   0 = Clarity with considerable details in recollection of events from childhood, early adulthood.
[]   1 = Memory for significant events of the past, but some uncertainty and lack of details.
[]   2 = Clear deficits in memory of personal history, some difficulty recalling names of familiar friends, relatives. Recalls place of birth, names of schools, occupation, major past events.
[]   3 = Unable to recall any significant historical events or places of schooling. May occasionally forget name of spouse or most frequent caregiver.
[]   4 = Difficulties with awareness of environment, sometimes able to distinguish familiar persons from unfamiliar persons, knows own name.
[]   5 = No comprehension of the nature of surroundings.

      C) Orientation
[]   0 = Fully oriented.
[]   1 = Some difficulty with time relationships, date not known, difficulty with year. May have problems with getting lost.
[]   2 = Usually disoriented in time, often disoriented to place.
[]   3 = Orientation to person only.
[]   4 = Body disorientation.
[]   5 = Totally lost, oblivious to posture.

II) Complex Attention
[]   0 = Can sustain attention for normal amount of time. Can divide attention without distraction.
[]   1 = Has mild lapses of attention, misses some details, not impairing daily function.
[]   2 = Has frequent distraction of attention, difficulty staying of subject, focusing on a task.
[]   3 = Attention impaired in daily activities; processing speed clearly slowed.
[]   4 = Poor attention to any specific activity without constant external input. Can be engaged only sporadically and briefly.
[]   5 = Unable to attend to any task or issue. No attention to surroundings or environmental events.

III) Executive Function, planning, decision-making, inhibition
      A) Judgement, problem solving, abstract thinking
[]   0 = Solves everyday problems well: judgment good in relation to past performance.
[]   1 = Mild difficulty in handling complex problems, similarities, differences, social judgment usually maintained.
[]   2 = Moderately impaired in handling problems; social judgment usually impaired.
[]   3 = Unable to make judgments, decisions, or solve problems.
[]   4 = Unable to carry a thought long enough to determine a purposeful course of action.
[]   5 = No response to any confronted problem.

IV) Language function, aphasia (dominant hemisphere)
[]   0 = Conversational, no searching for words.
[]   1 = Reticent conversation, searches for synonyms, word/name finding difficulties evident.
[]   2 = Vocabulary limitations noted in conversation, difficulty in naming objects.
[]   3 = Conversation limited to use of simple words and sentences. Can name simple objects but not uncommon objects.
[]   4 = Speech limited to single simple words, difficulty repeating single words, uncomprehending.
[]   5 = All verbal abilities lost, mute, unresponsive.

V) Perceptual-motor function

      A) Visuospatial organization, agnosia (non-dominant hemisphere)
[]   0 = No difficulty with three-dimensional perspectives; identifies the purpose of complex objects and can use them.
[]   1 = Mild difficulty copying complex three-dimensional perspectives, has difficulty recalling the purpose of unusual objects.
[]   2 = Considerable difficulty in reproducing simple drawings, can use simple objects only.
[]   3 = Unable to use writing implement for copying a simple design, misidentifies objects.
[]   4 = Can respond meaningfully only to some very familiar objects, e.g., may hold brush by handle, take pencil in hand, cannot full use these objects.
[]   5 = Unresponsive to objects in the environment.

      B) Home activities, motor coordination, praxis
[]   0 = Life at home, hobbies, crafts, intellectual interests well maintained.
[]   1 = Life at home, hobbies, intellectual interests only slightly impaired, trouble operating new appliances.
[]   2 = Mild impairment of function at home; more complicated hobbies and interests abandoned.
[]   3 = Only simple chores preserved, restricted interests poorly sustained, mild incoordination. Difficulty following instructions.
[]   4 = No significant function in home outside of own room. Dyspractic
[]   5 = Poor mobility, difficulty ambulating. May require manipulation and assistance. Apractic. May develop contractures of limbs.

VI) Social Cognition

      A) Community affairs, social function, and interactions with others
[]   0 = Independent function at usual level in job, shopping, business, and financial affairs, volunteer, and social groups.
[]   1 = Only doubtful or mild impairment, if any, in these activities.
[]   2 = Unable to function independently at these activities though may still be engaged in some; may still appear normal to casual inspection.
[]   3 = No pretense of independent function outside of home.
[]   4 = Impaired interactions with other individuals, loss of proper social interactions.
[]   5 = No interactions with other persons, frequent catastrophic reactions.

      B) Personal care, habits, hygiene
[]   0 = Fully capable of self-care, well-dressed and groomed by self.
[]   1 = Mild impairment of self-grooming, may need occasional prompting, needs some help in meeting nutritional needs.
[]   2 = Needs occasional prompting for dressing and grooming, needs help with nutritional needs.
[]   3 = Requires assistance in dressing, hygiene, keeping of personal effects. Able to feed self, but unable to prepare any of own food.
[]   4 = Requires full assistance with personal care, dressing, difficulty feeding self, frequent incontinence, diapers may be used.
[]   5 = Unable to dress self, difficulty with being fed, fully incontinent.

  0 -    5     normal, depending on age, education, complaints
  6 -  10     possible cognitive impairment
11 -  20     mild cognitive impairment
21 -  30     moderate cognitive impairment
31 -  40     severe cognitive impairment
41 -  50     profound/complete cognitive impairment

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